rockiesloan.ca Open in urlscan Pro
2606:4700:3030::ac43:82de Public Scan

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Submitted URL:
https://click.leadfox842.com/trackclicks/3497188a745ccdf6add120be4fcc8540/?tid=6632498f8b6d660007e5517c
Effective URL:
https://rockiesloan.ca/renew-your-loan/
Submission: On May 03 via manual (May 3rd 2024, 2:23:44 pm UTC) from US — Scanned from DE
Form analysis
1 forms found in the DOM

<form
  class="funnel-form__inner outer wrapper label element input help errors error decorator rangeValue uploadArea uploadAreaMask files file fileName fileAdd fileAddInput fileRemove fileProgress fileUploadError fileImagePreview fileImagePreviewImage fileProgressInner grouping groupRepeatable groupRepeatableRemove groupAddMore form formErrors formError">
  <!----> <!---->
  <div class="white-box">
    <div class="valid-check"><svg viewBox="0 0 28 28" fill="none" preserveAspectRatio="" width="28" height="28">
        <use xlink:href="#valid-check"></use>
      </svg></div>
    <div class="error-check"><svg viewBox="0 0 23 22" fill="none" preserveAspectRatio="" width="23" height="22">
        <use xlink:href="#exclamation-circle"></use>
      </svg></div>
    <div class="error-phone">
      <p>Need help filling the form?
        <a href="tel:18559094095" class="phone"><span class="icon"><svg viewBox="0 0 18 18" fill="none" preserveAspectRatio="" width="18" height="18"><use xlink:href="#phone"></use></svg></span> <span class="text">1-855-909-4095</span></a></p>
    </div>
    <div data-classification="group" data-type="group" class="formulate-input" data-has-errors="true">
      <div class="formulate-input-wrapper"><!----> <!---->
        <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
          <div class="formulate-input-group-repeatable"><!----> <!---->
            <div class="white-box__inner">
              <div class="funnel-form__box-title">Your Personal Info </div>
              <div class="form-row">
                <div class="form-control half"><label for="first_name" class="form-label">First Name*</label>
                  <div data-classification="text" data-type="text" class="form-input formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div data-type="text" class="formulate-input-element formulate-input-element--text"><!----> <input type="text" id="first_name" name="first name"> <!----></div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
                <div class="form-control half"><label for="last_name" class="form-label">Last Name*</label>
                  <div data-classification="text" data-type="text" class="form-input formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div data-type="text" class="formulate-input-element formulate-input-element--text"><!----> <input type="text" id="last_name" name="last name"> <!----></div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
              </div>
              <div class="form-row">
                <div class="form-control half"><label for="email" class="form-label">Email*</label>
                  <div data-classification="text" data-type="text" class="form-input formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div data-type="text" class="formulate-input-element formulate-input-element--text"><!----> <input type="text" id="email" name="email"> <!----></div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
                <div class="form-control half"><label for="b_year" class="form-label">Date of birth*</label>
                  <div class="form-multiple-selects">
                    <div data-classification="select" data-type="select" class="form-input year formulate-input" data-has-errors="true">
                      <div class="formulate-input-wrapper"><!----> <!---->
                        <div data-type="select" class="formulate-input-element formulate-input-element--select"><!----> <select data-placeholder-selected="true" placeholder="Year" id="b_year" name="year">
                            <option value="" hidden="hidden" disabled="disabled"> Year </option>
                            <option value="2006">2006</option>
                            <option value="2005">2005</option>
                            <option value="2004">2004</option>
                            <option value="2003">2003</option>
                            <option value="2002">2002</option>
                            <option value="2001">2001</option>
                            <option value="2000">2000</option>
                            <option value="1999">1999</option>
                            <option value="1998">1998</option>
                            <option value="1997">1997</option>
                            <option value="1996">1996</option>
                            <option value="1995">1995</option>
                            <option value="1994">1994</option>
                            <option value="1993">1993</option>
                            <option value="1992">1992</option>
                            <option value="1991">1991</option>
                            <option value="1990">1990</option>
                            <option value="1989">1989</option>
                            <option value="1988">1988</option>
                            <option value="1987">1987</option>
                            <option value="1986">1986</option>
                            <option value="1985">1985</option>
                            <option value="1984">1984</option>
                            <option value="1983">1983</option>
                            <option value="1982">1982</option>
                            <option value="1981">1981</option>
                            <option value="1980">1980</option>
                            <option value="1979">1979</option>
                            <option value="1978">1978</option>
                            <option value="1977">1977</option>
                            <option value="1976">1976</option>
                            <option value="1975">1975</option>
                            <option value="1974">1974</option>
                            <option value="1973">1973</option>
                            <option value="1972">1972</option>
                            <option value="1971">1971</option>
                            <option value="1970">1970</option>
                            <option value="1969">1969</option>
                            <option value="1968">1968</option>
                            <option value="1967">1967</option>
                            <option value="1966">1966</option>
                            <option value="1965">1965</option>
                            <option value="1964">1964</option>
                            <option value="1963">1963</option>
                            <option value="1962">1962</option>
                            <option value="1961">1961</option>
                            <option value="1960">1960</option>
                            <option value="1959">1959</option>
                            <option value="1958">1958</option>
                            <option value="1957">1957</option>
                            <option value="1956">1956</option>
                            <option value="1955">1955</option>
                            <option value="1954">1954</option>
                            <option value="1953">1953</option>
                            <option value="1952">1952</option>
                            <option value="1951">1951</option>
                            <option value="1950">1950</option>
                            <option value="1949">1949</option>
                            <option value="1948">1948</option>
                            <option value="1947">1947</option>
                            <option value="1946">1946</option>
                            <option value="1945">1945</option>
                            <option value="1944">1944</option>
                            <option value="1943">1943</option>
                            <option value="1942">1942</option>
                            <option value="1941">1941</option>
                            <option value="1940">1940</option>
                            <option value="1939">1939</option>
                            <option value="1938">1938</option>
                            <option value="1937">1937</option>
                            <option value="1936">1936</option>
                            <option value="1935">1935</option>
                            <option value="1934">1934</option>
                            <option value="1933">1933</option>
                            <option value="1932">1932</option>
                            <option value="1931">1931</option>
                            <option value="1930">1930</option>
                            <option value="1929">1929</option>
                            <option value="1928">1928</option>
                            <option value="1927">1927</option>
                            <option value="1926">1926</option>
                            <option value="1925">1925</option>
                            <option value="1924">1924</option>
                          </select> <!----></div> <!---->
                      </div> <!----> <!---->
                    </div>
                    <div data-classification="select" data-type="select" class="form-input month formulate-input" data-has-errors="true">
                      <div class="formulate-input-wrapper"><!----> <!---->
                        <div data-type="select" class="formulate-input-element formulate-input-element--select"><!----> <select data-placeholder-selected="true" placeholder="Month" id="b_month" name="month">
                            <option value="" hidden="hidden" disabled="disabled"> Month </option>
                            <option value="01">January</option>
                            <option value="02">February</option>
                            <option value="03">March</option>
                            <option value="04">April</option>
                            <option value="05">May</option>
                            <option value="06">June</option>
                            <option value="07">July</option>
                            <option value="08">August</option>
                            <option value="09">September</option>
                            <option value="10">October</option>
                            <option value="11">November</option>
                            <option value="12">December</option>
                          </select> <!----></div> <!---->
                      </div> <!----> <!---->
                    </div>
                    <div data-classification="select" data-type="select" class="form-input day formulate-input" data-has-errors="true">
                      <div class="formulate-input-wrapper"><!----> <!---->
                        <div data-type="select" class="formulate-input-element formulate-input-element--select"><!----> <select data-placeholder-selected="true" placeholder="Day" id="b_day" name="day">
                            <option value="" hidden="hidden" disabled="disabled"> Day </option>
                            <option value="01">01</option>
                            <option value="02">02</option>
                            <option value="03">03</option>
                            <option value="04">04</option>
                            <option value="05">05</option>
                            <option value="06">06</option>
                            <option value="07">07</option>
                            <option value="08">08</option>
                            <option value="09">09</option>
                            <option value="10">10</option>
                            <option value="11">11</option>
                            <option value="12">12</option>
                            <option value="13">13</option>
                            <option value="14">14</option>
                            <option value="15">15</option>
                            <option value="16">16</option>
                            <option value="17">17</option>
                            <option value="18">18</option>
                            <option value="19">19</option>
                            <option value="20">20</option>
                            <option value="21">21</option>
                            <option value="22">22</option>
                            <option value="23">23</option>
                            <option value="24">24</option>
                            <option value="25">25</option>
                            <option value="26">26</option>
                            <option value="27">27</option>
                            <option value="28">28</option>
                            <option value="29">29</option>
                            <option value="30">30</option>
                            <option value="31">31</option>
                          </select> <!----></div> <!---->
                      </div> <!----> <!---->
                    </div>
                  </div>
                </div>
              </div>
              <div class="form-row">
                <div class="form-control half"><label for="phone" class="form-label">Home Phone Number*</label>
                  <div data-classification="text" data-type="text" class="form-input formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div data-type="text" class="formulate-input-element formulate-input-element--text"><!----> <input type="text" vfe-mask="(000) 000-0000" id="cell" name="home phone"> <!----></div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
                <div class="form-control half"><label for="cell" class="form-label">Cell Phone Number*</label>
                  <div data-classification="text" data-type="text" class="form-input formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div data-type="text" class="formulate-input-element formulate-input-element--text"><!----> <input type="text" vfe-mask="(000) 000-0000" id="cell" name="cell phone"> <!----></div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
              </div>
            </div>
          </div> <!----> <!---->
        </div> <!---->
      </div> <!----> <!---->
    </div>
  </div>
  <div class="white-box">
    <div class="valid-check"><svg viewBox="0 0 28 28" fill="none" preserveAspectRatio="" width="28" height="28">
        <use xlink:href="#valid-check"></use>
      </svg></div>
    <div class="error-check"><svg viewBox="0 0 23 22" fill="none" preserveAspectRatio="" width="23" height="22">
        <use xlink:href="#exclamation-circle"></use>
      </svg></div>
    <div class="error-phone">
      <p>Need help filling the form?
        <a href="tel:18559094095" class="phone"><span class="icon"><svg viewBox="0 0 18 18" fill="none" preserveAspectRatio="" width="18" height="18"><use xlink:href="#phone"></use></svg></span> <span class="text">1-855-909-4095</span></a></p>
    </div>
    <div data-classification="group" data-type="group" class="formulate-input" data-has-errors="true">
      <div class="formulate-input-wrapper"><!----> <!---->
        <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
          <div class="formulate-input-group-repeatable"><!----> <!---->
            <div class="white-box__inner">
              <div class="funnel-form__box-title">Residential Information</div>
              <div class="form-row">
                <div class="form-control flex"><label for="same-address" class="form-label">Has your mailing address changed since your last application with us?*</label>
                  <div data-classification="group" data-type="radio" class="form-inline-box formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="same-address_yes" name="same-address" value="yes"> <label for="same-address_yes"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="same-address_yes" class="formulate-input-label formulate-input-label--after">Yes</label>
                          </div> <!----> <!---->
                        </div>
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="same-address_no" name="same-address" value="no"> <label for="same-address_no"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="same-address_no" class="formulate-input-label formulate-input-label--after">No</label>
                          </div> <!----> <!---->
                        </div> <!---->
                      </div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
              </div> <!---->
            </div>
          </div> <!----> <!---->
        </div> <!---->
      </div> <!----> <!---->
    </div>
  </div>
  <div class="white-box">
    <div class="valid-check"><svg viewBox="0 0 28 28" fill="none" preserveAspectRatio="" width="28" height="28">
        <use xlink:href="#valid-check"></use>
      </svg></div>
    <div class="error-check"><svg viewBox="0 0 23 22" fill="none" preserveAspectRatio="" width="23" height="22">
        <use xlink:href="#exclamation-circle"></use>
      </svg></div>
    <div class="error-phone">
      <p>Need help filling the form?
        <a href="tel:18559094095" class="phone"><span class="icon"><svg viewBox="0 0 18 18" fill="none" preserveAspectRatio="" width="18" height="18"><use xlink:href="#phone"></use></svg></span> <span class="text">1-855-909-4095</span></a></p>
    </div>
    <div data-classification="group" data-type="group" class="formulate-input" data-has-errors="true">
      <div class="formulate-input-wrapper"><!----> <!---->
        <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
          <div class="formulate-input-group-repeatable"><!----> <!---->
            <div class="white-box__inner">
              <div class="funnel-form__box-title">Employment information</div>
              <div class="form-row">
                <div class="form-control flex"><label for="same-job" class="form-label">Has your employment or income changed since your last application with us?*</label>
                  <div data-classification="group" data-type="radio" class="form-inline-box formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="same-job_yes" name="same-job" value="yes"> <label for="same-job_yes"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="same-job_yes" class="formulate-input-label formulate-input-label--after">Yes</label>
                          </div> <!----> <!---->
                        </div>
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="same-job_no" name="same-job" value="no"> <label for="same-job_no"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="same-job_no" class="formulate-input-label formulate-input-label--after">No</label>
                          </div> <!----> <!---->
                        </div> <!---->
                      </div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
              </div> <!---->
            </div>
          </div> <!----> <!---->
        </div> <!---->
      </div> <!----> <!---->
    </div>
  </div>
  <div class="white-box">
    <div class="valid-check"><svg viewBox="0 0 28 28" fill="none" preserveAspectRatio="" width="28" height="28">
        <use xlink:href="#valid-check"></use>
      </svg></div>
    <div class="error-check"><svg viewBox="0 0 23 22" fill="none" preserveAspectRatio="" width="23" height="22">
        <use xlink:href="#exclamation-circle"></use>
      </svg></div>
    <div class="error-phone">
      <p>Need help filling the form?
        <a href="tel:18559094095" class="phone"><span class="icon"><svg viewBox="0 0 18 18" fill="none" preserveAspectRatio="" width="18" height="18"><use xlink:href="#phone"></use></svg></span> <span class="text">1-855-909-4095</span></a></p>
    </div>
    <div data-classification="group" data-type="group" class="formulate-input" data-has-errors="true">
      <div class="formulate-input-wrapper"><!----> <!---->
        <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
          <div class="formulate-input-group-repeatable"><!----> <!---->
            <div class="white-box__inner">
              <div class="funnel-form__box-title">Banking information</div>
              <div class="form-row">
                <div class="form-control flex"><label for="same-bank" class="form-label">Have you changed your banking info since your last application with us?*</label>
                  <div data-classification="group" data-type="radio" class="form-inline-box formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="same-bank_yes" name="same-bank" value="yes"> <label for="same-bank_yes"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="same-bank_yes" class="formulate-input-label formulate-input-label--after">Yes</label>
                          </div> <!----> <!---->
                        </div>
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="same-bank_no" name="same-bank" value="no"> <label for="same-bank_no"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="same-bank_no" class="formulate-input-label formulate-input-label--after">No</label>
                          </div> <!----> <!---->
                        </div> <!---->
                      </div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
              </div> <!---->
            </div>
          </div> <!----> <!---->
        </div> <!---->
      </div> <!----> <!---->
    </div>
  </div>
  <div class="white-box loan">
    <div class="valid-check"><svg viewBox="0 0 28 28" fill="none" preserveAspectRatio="" width="28" height="28">
        <use xlink:href="#valid-check"></use>
      </svg></div>
    <div class="error-check"><svg viewBox="0 0 23 22" fill="none" preserveAspectRatio="" width="23" height="22">
        <use xlink:href="#exclamation-circle"></use>
      </svg></div>
    <div class="error-phone">
      <p>Need help filling the form?
        <a href="tel:18559094095" class="phone"><span class="icon"><svg viewBox="0 0 18 18" fill="none" preserveAspectRatio="" width="18" height="18"><use xlink:href="#phone"></use></svg></span> <span class="text">1-855-909-4095</span></a></p>
    </div>
    <div data-classification="group" data-type="group" class="formulate-input" data-has-errors="true">
      <div class="formulate-input-wrapper"><!----> <!---->
        <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
          <div class="formulate-input-group-repeatable"><!----> <!---->
            <div class="white-box__inner">
              <div class="funnel-form__box-title">Loan information</div>
              <div class="form-row">
                <div class="form-control half"><label for="amount" class="form-label">Amount*</label>
                  <div data-classification="select" data-type="select" class="form-input formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div data-type="select" class="formulate-input-element formulate-input-element--select"><!----> <select id="amount" name="amount"><!---->
                          <option disabled="disabled" value="">Choose...</option>
                          <option value="750">$750</option>
                          <option value="700">$700</option>
                          <option value="600">$600</option>
                          <option value="500">$500</option>
                        </select> <!----></div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
                <div class="form-control half"><label for="next_pay" class="form-label">Next pay deposit*</label>
                  <div data-classification="text" data-type="date" class="form-date formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div data-type="date" class="formulate-input-element formulate-input-element--date"><!----> <input type="date" placeholder="YYYY-MM-DD" min="2024-05-03" id="next_pay" name="next pay"> <!----></div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
              </div>
              <div class="form-row">
                <div class="form-control"><label for="deposit" class="form-label"> How would you like to receive your funds?* <span class="info"><svg viewBox="0 0 16 16" fill="none" preserveAspectRatio="" width="16" height="16">
                        <use xlink:href="#circled-info"></use>
                      </svg></span> <span class="info-deposit">How would you like to receive your funds?<span class="tooltipstext"><span style="color: rgb(255, 75, 75);"><strong>Direct Deposit(Free)</strong></span> – Funds are deposited
                        <strong>directly into your account</strong> the same day of approval so long your application is approved by 2:30PM EST.<br><br><span style="color: rgb(0, 160, 56);"><strong>Instant Deposit(+$5.00)</strong></span> – Your funds
                        will be deposited <strong>directly into your account</strong> within 1 - 2 hours of approval.<br><br><span style="color: rgb(127, 165, 249);"><strong>Interact E-Transfer(+$3.00)</strong></span> – The funds will be sent to the
                        <strong>email address associated</strong> to your file and you can expect the funds within 3 hours of approval.</span></span></label> <!---->
                  <div data-classification="group" data-type="radio" class="form-inline-box formulate-input" data-has-errors="true">
                    <div class="formulate-input-wrapper"><!----> <!---->
                      <div role="group" class="formulate-input-element formulate-input-element--group formulate-input-group"><!---->
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="deposits_direct" name="deposits" value="direct"> <label for="deposits_direct"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="deposits_direct" class="formulate-input-label formulate-input-label--after">Direct Deposit</label>
                          </div> <!----> <!---->
                        </div>
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="deposits_instant" name="deposits" value="instant"> <label for="deposits_instant"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="deposits_instant" class="formulate-input-label formulate-input-label--after">Instant Deposit</label>
                          </div> <!----> <!---->
                        </div>
                        <div data-classification="box" data-type="radio" class="formulate-input-group-item formulate-input">
                          <div class="formulate-input-wrapper"><!----> <!---->
                            <div data-type="radio" class="formulate-input-element formulate-input-element--radio"><!----> <input type="radio" hasgivenname="true" id="deposits_interac" name="deposits" value="interac"> <label for="deposits_interac"
                                class="formulate-input-element-decorator"></label> <!----></div> <label for="deposits_interac" class="formulate-input-label formulate-input-label--after">Interac E-Transfer</label>
                          </div> <!----> <!---->
                        </div> <!---->
                      </div> <!---->
                    </div> <!----> <!---->
                  </div>
                </div>
              </div>
              <div class="form-row"><!----></div>
            </div>
          </div> <!----> <!---->
        </div> <!---->
      </div> <!----> <!---->
    </div>
  </div>
  <div class="smartHidden">
    <div data-classification="text" data-type="text" class="form-input formulate-input">
      <div class="formulate-input-wrapper"><!----> <!---->
        <div data-type="text" class="formulate-input-element formulate-input-element--text"><!----> <input type="text" id="formulate-global-29"> <!----></div> <!---->
      </div> <!----> <!---->
    </div>
  </div> <!---->
  <div data-classification="button" data-type="submit" class="form-submit formulate-input">
    <div class="formulate-input-wrapper"><!----> <!---->
      <div data-type="submit" class="formulate-input-element formulate-input-element--submit"><!----> <button type="submit" id="formulate-global-30"><span class="btn__text">CLAIM YOUR CASH!</span> <span class="btn__icon"><svg viewBox="0 0 16 17"
              fill="none" preserveAspectRatio="" width="16" height="17">
              <use xlink:href="#arrow-right"></use>
            </svg></span></button> <!----></div> <!---->
    </div> <!----> <!---->
  </div>
  <div class="form-note"> By submitting this form, I confirm that the information I provided is exact and current, and that I have read and accepted <a href="/terms-and-conditions/">the terms and conditions</a>. I accept periodical contact by
    RockiesLoan by email with promotions or updates regarding my account. </div>
</form>
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